HISTORIA Y PROCESO LEGISLATIVO:
FE DE ERRATAS AL DECRETO 605
This step needs to be fully debriefed. In particular, you need to ensure that the participants are using the information and issues raised in Steps 2 and 3, exploring the dilemmas and contradictions that they pose, rather than just talking about things in general.
REFLECTION ON THE BROADER USE OF SYSTEMS IDEAS TO ECOHEALTH RESEARCH
This module has focused on the early stages of designing an Ecohealth research intervention.
As a whole group, discuss how systems ideas, especially the three key dimensions of interrelationships, perspectives, and boundaries could influence how you undertake these other stages of an Ecohealth research project:
• Method selection
• Fieldwork and data collection • Analysis
• Reporting
Sample Timetable: Module 4
TIME INTENSE SHORT COURSE (1 DAY)
08:30-09:00 Activity 1, Introduction and warm up: Brainstorming on dengue
fever issues.
09:00-9:30 Activity 2, Reading handout on interrelationships, perspectives,
and boundaries.
09:30-10:00 Activity 3, Grouping ideas into interrelationships, perspectives,
and boundaries. Reflection.
10:00-10:30 Break
10:30-11:30 Activity 4, Step 1, Construct a rich picture map of case study. 11:30-12:30 Activity 4, Step 2, Frame the situation.
12:30-13:30 Lunch
13:30-15:00 Activity 4, Step 3, Consider the ethical and pragmatic
consequences of framings.
15:00-15:15 Break
15:15-16:30 Activity 4, Step 4, Assess the dynamics. 16:30-17:00 Wrap up and evaluation.
Evaluation
Refer to Modules 1 and 2 for suggestions on evaluating this topic.
Terminology
Agent
A component of a situation. It could be people or things. Often the nodes of network relationships.
Boundary
Marks an important distinction between two features of a situation. It determines what is “in” (included) or what is “out” (excluded), what’s important or relevant and what is unimportant or irrelevant, what is emphasized and what is marginalized.
Boundary decision
The choice of where to place a boundary.
Boundary critique
The means by which you consider the implications of particular boundary decisions.
Complex situations
Situations whose behaviour is knowable only after the fact; uncertain and unpredictable. (Uncertainty is also a large area of study in its own right).
Complicated situations
Situations whose behaviour is knowable but not necessarily known, and once known is relatively predictable.
Context
Something that affects how a situation behaves but over which that situation has little influence or control. History is often an important aspect of context.
Dynamic
How agents interrelate and the consequences of those interrelationships over time.
Feedback
The phenomenon where an output of a process becomes the input of the same process. In most situations, these feedbacks work over different time periods.
Framing
A collection of perspectives that help you make sense of a situation in a particular way.
Input
Something that is changed by a process.
Interrelationship
Connections between components or agents within a situation.
Marginalization
In boundary setting, an aspect of a situation is marginalized if it is considered unimportant.
Network
A set of interrelationships between objects or agents.
Object
A component of a situation. It could be people or things, and is often the node of network relationships.
Output
The result of a process.
Pattern
A set of repeated behaviours.
Perspective
Values, assumptions, and viewpoints that stakeholders bring to a situation.
Problem
A situation that is of some concern or that contains issues that need resolving.
Rich picture
A graphic means of displaying key features of a situation that is unstructured and unfettered by pre-conceived views and ideas.
Simple situations
Situations whose behaviour is wholly known and predictable.
Situation
The set of circumstances that are of interest to us and on which we intend to apply systems concepts.
Situation or situation of interest
In systems language, a state of affairs that is of interest to you that you wish to explore further or intervene in.
Stake
Motivations, world views, and other factors that could benefit or be at risk.
Stakeholder
Someone or something that can affect or be affected by a situation or any action to address a situation.
System
Within this module the word “system” is used to describe a model of a set of interrelationships, within certain boundaries, that we wish to study and/or change.
Systems thinking
A means of understanding the world holistically, using concepts of interrelationships, perspectives, and boundaries.
Worldview
A set of values and attitudes that influence how you engage with a situation.
Key References
Much material about systems ideas is available on the Internet. Two key sites are:
• Bob Williams’ website: http://www.bobwilliams.co.nz • Open University: http://openlearn.open.ac.uk/
Publications
Waltner-Toews, D. (2011). Ecohealth: a primer. Available at ecohealth.vetswithoutborders.ca.
Waltner-Toews, D., Kay, J.J., and Lister, N.M. (eds) (2008). The ecosystem approach: complexity, uncertainty, and managing for sustainability. New York: Columbia University Press. (This volume introduces many of the ideas discussed in this module, along with case studies focusing on ecosystem approaches to health, agriculture, and environmental management.)
Williams, B., and Hummelbrunner, R. (2011). Systems concepts in action: a practitioner’s toolkit. Stanford University Press.
Williams, B. (2011). All methods are wrong, some methods are useful. How to choose between systems principles and systems methods. The Systems Thinker, 22 (4). Pegasus Communications, Inc.
Additional References
Rich Picturing
Bunch, M.J., McCarthy, D., and Waltner-Toews, D. (2008). A family of origin for an ecosystem approach to managing for sustainability. In: Waltner- Toews, D., Kay, J.J., Lister, NM (eds) The ecosystem approach: complexity, uncertainty, and managing for sustainability. New York: Columbia University Press.
Reynolds, M. Open University, UK. Available at:
http://openlearn.open.ac.uk/mod/oucontent/view.php?id=406458§ ion=3.1 Accessed May 2012
Systems thinking and practice: diagramming. Course Material T552. Open University.
http://systems.open.ac.uk/materials/T552/pages/rich/rich.html Accessed February 2012.
Boundaries
Flood, R. L., and Ulrich, W. (1990). Conversations on critical systems thinking. In R. L. Flood and M C. Jackson (eds). Critical Systems Thinking: Directed Readings. Chichester: Wiley.
Reynolds, M. and Williams, B. (2012). Evaluation for equity: fostering development results, in Evaluation for Equity, UNICEF.
MODULE 4 − HANDOUT 1 − ACTIVITY 1
Case study: Dengue Fever Prevention
Note: This case study is about a multi-agency research project in urban and
peri-urban Thailand. It is based on an action research Ecohealth intervention. This description outlines only the main points of the intervention and, for the purposes of this course, does not describe the intervention itself or its outcomes. Essentially you are going to design the intervention during this session.
Aspects of the case that will emerge during the exercise are not fully covered in this description. This is done deliberately to allow you to uncover these aspects as you work through the case study.
CONTROL OF DENGUE VECTORS IN URBAN AND PERIURBAN SETTINGS IN THAILAND
BACKGROUND
Dengue fever is considered one of the most important vector-borne diseases in Thailand and its incidence is increasing despite routine implementation of national dengue control programs. This study aimed to demonstrate application of integrated, community-centred, eco-bio-social strategies in combination with locally produced ecofriendly vector control tools within the dengue control program, focusing on urban and peri-urban settings in eastern Thailand.
Dengue has four viral serotypes (variations of virus types) and there is still no available quadrivalent vaccine (i.e. which applies to all four virus types). Control efforts in most countries, including Thailand, therefore have focused on controlling the mosquito vectors (carriers of the virus), especially Aedes aegypti.
With regards to ecological factors that contribute to dengue transmission, research findings have shown that the dengue virus, human host populations, and ecosystems show features of complex systems. Other investigations related to environmental and climatic factors have revealed that nutrients and temperatures could affect the growth development and survival of Aedes larvae, shorten the period during which the virus replicates in the mosquito’s body (extrinsic incubation period), and increase the incidence of dengue fever, while an increase of rainfall could cause a decrease of incidence.
From the initial program in the 1960s, the Ministry of Public Health of Thailand has concentrated on vector control for dengue by spraying insecticide to control adult mosquitoes and using temephos (1% abate sand granules) to control larval stages. However, despite having established intensive vector control programs and vector surveillance strategies all over
the country, suppression of dengue transmission has not been fully achieved, as indicated by the number of reported cases in Thailand over the past 10 years (more than 30,000 per year). The lack of efficacy of ultra-low volume (ULV) and thermal fog application techniques has led to a re-evaluation of recommended strategies for prevention and control of mosquito vectors, and strategies ranging from integrated approaches to community participation have been considered. Moreover, the consequences of intensive use of insecticides have caused insecticide resistance in many insects including mosquito vectors, and insecticide residues retained in the food chain affect many life forms, including soil bacteria and plants. For these reasons, the trend in dengue vector control has shifted away from the use of chemical- based control to biological-based control and source reduction/environmental management through community participation.
Research has shown that residential mixed with commercial and densely populated urban residential areas clearly exhibited the highest risk for dengue incidence. This suggests that dengue control programs could focus on this kind of urban ecosystem, especially during an economic crisis when there are lower budgets for such programs.
Although many research attempts have provided diverse lines of evidence about the drivers of vector abundance, virus circulation, and dengue transmission, they have not taken an integrated approach to investigating all of these factors together. Such a single-focus approach is no longer considered effective for figuring out the complexity of factors underlying the three epidemiological components. Theoretically, comprehensive dengue management requires getting an insight into the holistic disciplines that can assess the driving determinants and how they significantly interact. The need for interdisciplinary integration of ecological, biological, and socio- demographic dimensions of dengue has been recently confirmed by dengue experts in different disciplines.
ECOHEALTH RESEARCH
The intervention site in Thailand was in Chachoengsao Province, located approximately 120 km east of Bangkok. This province is representative of the geographic, social, economic, and epidemiologic situation in most of Thailand. Dengue (DHF) incidence exhibited a strong seasonal pattern in the province, with high transmission during the rainy season. The peak outbreaks of dengue were in 1987 and 2001, as in other provinces. In general, households and buildings were more tightly packed and infrastructure (connecting roads, electric service, and tap water supply) was better in urban settings as compared to peri-urban areas. In all the study areas, both tap water and rainwater were used by households, and although the piped water supply was reliable, people still stored water in various types of containers. An efficient municipal waste management system was in place.
Indoor spraying and fogging was intensively used in the high endemic area, while preventive measures were markedly applied in the low endemic area. A majority of the stakeholders involved in the dengue problem and vector
control were public health service offices. Dengue control activities in this area were mainly driven by public health authorities who are directly in charge, whereas other respective stakeholders rarely participate in control programs. The key breeding containers were found to be water storage jars, cement baths/basins, and buckets. Before intervention, 7095 containers were inspected, yielding 1231 pupae in 231 containers, and leading to the mean pupae per person index of 0.38. A considerable proportion of the respondents in low dengue transmission areas possessed sufficient overall knowledge about dengue, whereas respondents in high dengue transmission area did not.
Thanks to the following authors for allowing this adaptation of their published work: Pattamaporn Kittayapong, Piyarat Butraporn, Surachart Koyadun, Chitti Chansang, Suporn Thongyuan, Rungrith Kittayapong, P. Olanratmanee, and W. Aumchareon.
MODULE 4 − HANDOUT 2 − ACTIVITY 2
Three Core Concepts: Interrelationships,
Perspectives, and Boundaries
Systems thinking is one of the six core principles of the Ecohealth approach (Charron 2012). But what does it mean to conduct Ecohealth research in a way that uses systems principles and ideas? What does it mean in practice? What does it mean for the design, practice, analysis, and reporting of Ecohealth research?
What does “systemic” mean to you? What enters your mind when you read the word? Perhaps something like “looking at the big picture,” or “being aware of how things link together,” or “even seeing things from lots of viewpoints.” These are all very fine ideas, but no great help when confronted with the kind of tricky problem or messy situation that confronts you when dealing with designing and carrying out some Ecohealth work. After all, the “big picture,” complicated relationships, and multiple perspectives are what made the problem or situation difficult toaddress in the first place.
So what does being systemic or thinking systemically mean in practice? A bit of history helps.
Systems ideas can be traced back many thousands of years, but the modern systems movement traces its lineage to the middle of the twentieth century, starting in the 1930s and accelerated during the Second World War. You can recognize three main phases since then.
From the early days until the late 1960s, the focus of the systems field was very much on interrelationships. This period represented the “wiring diagram” phase of thinking systemically and is still influential today. Indeed some of the maps in other modules (e.g. network maps, concept maps) originated during this first phase).
By the early 1970s, many people in the systems field felt that focusing entirely on interrelationships, while important, was not as useful as it appeared. For instance, the relative importance of particular interrelationships often depended on the different perspectives through which people observed a situation, usually reflecting what they have already experienced, think is most important, or value most highly. Think briefly of the first exercise today – there are probably many perspectives represented. Thus systemic thinking began to include the implications of applying different perspectives, world views, or framings to the same situation.
By the mid-1980s, some systems thinkers concluded that focusing on perspectives had its problems. Perspectives influence what we consider relevant or irrelevant; they determine what is “in” our framing of a situation (the way we understand a situation) and what lies “outside” that framing. Whoever defines the dominant perspective controls the boundary of a
systemic inquiry or intervention; this underlines the importance of addressing questions of power, gender, and equity that were raised in other modules. This reflects the understanding that a complex systems model is the result of what is being observed (the “real world” outside ourselves) and who is doing the observing. Thus, the importance of studying boundaries and critiquing boundary decisions (including those who made them) is the third core concept underpinning a systems approach, and related closely to the kinds of questions raised in the participatory and equity modules.
So let us look at each of these concepts in turn.
INTERRELATIONSHIPS
Many newcomers to the systems field are familiar with the idea of interrelationships. Questions of how things are connected and with what consequence stem from the earliest thinking about systems. It is also the concept most strongly embedded in the popular imagination. When we talk about the education system or the health system, we imagine a set of objects and processes that are inter-connected in some way. The popularity of system dynamics and complex adaptive systems in many parts of the world cements the notion that interrelationships are an important systems concept.
However, systemic thinking doesn’t concern itself with just any interrelationships. It focuses on particular aspects of them:
• How the interrelationships affect the behaviour of a situation over a period of time (dynamic aspects).
• How the size of the output or effect of interrelationships appears unrelated to the size of the input to the interrelationship. This is often but not always caused by “feedback” (non-linear aspects). The simplest example of non-linear relationships is exponential growth patterns familiar in ecology and your bank account (“non-linear” in the sense that it is an exponential curve, “feedback” in the sense that “the more there is, the more opportunity there is for more”).
• How the same interrelationships in different contexts have different results (Sensitivity to Context). Disease control methods which work in Thailand may not work in the Philippines.
• How to understand interrelationships that are so complicated or complex that you cannot assess them in terms of simple cause and effect.
When studying interrelationships systemically we ask the first five of the 12 questions we will be considering:
1. What is the structure of the interrelationships within the situation (i.e. how are the components arranged)?
3. What is the nature of the interrelationships (e.g. strong, weak, fast, slow, conflicted, collaborative, direct, indirect)?
4. What are the patterns that emerge from these interrelationships over time, with what consequences and for whom?
5. What are ways in which these complicated and complex dynamics can be identified and managed effectively?
Note that the very idea of interrelationships assumes that we have already set boundaries around the situation we wish to study and/or change, and we have already assumed certain perspectives. One of the challenges of systemic approaches is they are themselves systemic, and the characteristics we are concerned with are interrelated. We “take them apart” in order to better understand them. Indeed, later in this module the 12 questions are put together in a sequence that addresses this issue.
PERSPECTIVES
A systemic approach, however, is more than describing how things fit together or networks operate. Just looking at interconnections does not make an inquiry or intervention systemic. What makes it systemic is how you look at the interrelationships. People will see and interpret those interrelationships in different ways depending on their perspectives. A local cafe owner might view issues to do with preventing the spread of dengue quite differently than someone from the health service, even though they may “see” the same thing. The Kathmandu case study described at the end of the Ecohealth Primer (and summarized in Charron’s book) includes a situation in which restaurant owners and customers both knew the water was contaminated. The owners did not boil their drinking water because customers didn’t want them to; the customers feared that if the water were boiled, they would lose immunity to local bacteria. The public health researchers “saw” the same thing, but drew different conclusions. Although it is useful to explore perspectives for getting a more comprehensive understanding of the situation, there is an even more important benefit. What a health inspector does when he or she “sees” a cafe premises will be different from what the cafe owner does when he or she “sees” the same thing. Our perceptions promote behaviours that affect the way a situation unfolds. Indeed what we see as unintended patterns within a situation often result from our unwillingness to understand or explore other people’s perceptions. We write these behaviours off as “unintended” without considering that somebody, somewhere, may indeed have intended the result that we consider a problem. Thus we cannot comprehend the dynamics of a situation without identifying and understanding the range of relevant perspectives that people bring to it.
It’s helpful to distinguish between three forms of perspective: stakeholders, stakes, and framings.
Stakeholders are groups of people or things that have a common role in a situation or intervention (e.g. teachers, consumers, writers). In contrast, stakes relate to individual values and motivations (e.g. wealth, honour, fairness, past
history, purpose, ideas of professionalism), that is, what matters to the stakeholders. People belonging to different stakeholder groups may share the